Case scenarios- Neck Swelling Abdulaziz Alsaigh FRCS, FACS Professor of Surgery

Case scenario 1 A 60- year old female presented with neck swelling for 4 months, dyspnea and hoarseness of voice for 1 month. She is in your clinic. ? What to do.

History History of neck swelling: How noticed? Often noticed by others Duration? Acute or chronic Painful- acute lymphadenitis, thyroiditis, bleeding in goitre, submandibular salivary gland stone *Painless- chronic lymphadenopathy, goitre, branchial cyst *Change in size: Rapid increase- infection, bleeding, malignant change. Slow increase in neoplasms Single or multiple? Multiple- lymph nodes

Other symptoms *Voice change ( malignant invasion) Dysphagia ( pressure on esophagus) *Dyspnea (pressure on trachea) Eye symptoms Throat pain , Oral ulcer , Nasal symptoms, Scalp lesion

Systemic symptoms Lymphadenopathy: Fever, night sweating, contact with infectious disease, weight loss, change in appetite, respiratory/ gastrointestinal symptoms. Goitre: Nervousness, tremor, weight loss/ gain, palpitation, preference to cold/ warm weather, muscle fatigue, sweating

Systemic inquiry GI – appetite, wt. change, bowel habit (thyroid, LN) RS- dyspnea on exertion, (retrosternal extension) CVS- palpitation, ankle swelling GU- amenorrhea CNS- nervousness, irritability, insomnia (thyrotoxicosis) Endocrines- preference to warm or cold weather

This patient PMH- Nil significant, no neck radiation Neck swelling Painless Slow increase Dyspnea Voice change PMH- Nil significant, no neck radiation FH of neck /thyroid malignancies- NAD Medication/allergies- nil

General Examination Appearance- NAD Eye- NAD Hand tremors- NAD Tachycardia- NAD

Local Examination Inspection- solitary mass, left anterior triangle, moving up on deglutition Palpation: Left lobe- 3x3 cm hard mass , non-tender. Rt. Lobe- normal Multiple ipsilateral LAP, Trachea shifted to right side Percussion - NAD Auscultation- NAD

Differential Diagnosis Clinical: Goitre, Thyroid mass Functional- ?Hyper, hypo, Normothyroid ? Pathological- Diff. diagnosis MNG, Thyroiditis, Cyst Thyroid neoplasms ? Which type

Thyroid malignancy Papillary Follicular Hurthle cell MTC (sporadic / familial MEN 2 A (Sipple syndrome- MTC, pheo, HPT, lichen planus amyloidosis, Hirschsprung's dis.) MEN2B (MTC, pheo, marfanoid, mucosal neuromas, ganglioneuroma of GIT) Anaplastic Lymphoma

Differential diagnosis Papillary carcinoma Anaplastic carcinoma MTC Lymphoma

Investigations US FNA- PC (malignant, non-diagnostic, benign) TFT CXR CT Indirect laryngoscopy: Lt RL nerve palsy Surgery

Inconclusive FNA Non-diagnostic/ cellular – repeat Repeat FNA- inconclusive TSH level- normal/high- surgery TSH low- nuclear scan Low uptake- surgery, High uptake- FU or therapy)

Thyroidectomy for thyroid nodule (Indications) Malignant nodule Progressively enlarging nodule Pressure symptoms Suspicious nodule (FNA failed to establish a benign nature) Thyrotoxic nodule

Total thyroidectomy Malignant tumours ? Neck lymph node dissection RIA (Radio iodine ablation)- large tumour, metastasis, local tumour extension Complications: Bleeding, hypoparathyroidism, recurrent laryngeal nerve injury

Case 2: 12-year old boy presented with a neck swelling

Thyroglossal cyst Midline swelling Moves upwards with protrusion of the tongue Aetiology- persistence of part of thyroglossal duct Treatment: Excision with a central wedge of hyoid bone ( tract run either superficial of deep to hyoid)

Case 3 A 35-year old female presented with multiple neck swellings for 3 months ?History

The patient History of lump: multiple, painless Systemic inquiry: Fever, loss of weight, night sweat, no cough Examination: multiple, some discrete, some matted, firm swellings ENT, chest, abdomen- NAD Diagnosis / DD : ? Investigation

TB lymphadenitis Painless, initially firm swelling, later may become soft (cold abscess), Matted, discharging sinus Evening fever, night sweats, wt. loss, anorexia Diagnosis: FNA, aspirate for AFB, culture, PCR, biopsy Treatment: Anti-tuberculous drugs

Case 4 Presented with a painful swelling

Parotid abscess Tender parotid swelling with fever and malaise Pus exuding from duct papilla Staph. aureus, Strep. viridans Early cases: antibiotics, oral hygiene Late cases: abscess drainage

Case 5 Painless swelling for 1 year

Salivary gland neoplasms BENIGN: Pleomorphic adenoma Warthin’s tumour Oncocytoma, Basal cell adenoma, Intraductal papilloma MALIGNANT: Mucoepidermoid carcinoma* Acinic cell carcinoma Adenoid cystic carcinoma Basal cell carcinoma Low grade adenocarcinoma Mucinous adenocarcinoma Malignant pleomorphic tumour Lymphoma

Pleomorphic Adenoma Most common neoplasm, parotid most common site M=F, 3-5 decade Slow growing, painless mass/ mild discomfort Risk of malignant change- 1.5% in 5 years FNA- most helpful CT, MRI rarely needed Treatment: Superficial parotidectomy / Total parotidectomy Enucleation- not recommended Submandibular: Total gland excision

Thank you!